Health Spending Account

+ RRSP Option

9 No annual inflationary increases - employer defines annual cost

9 No wasted premiums - unspent HSA amounts carry forward to 2nd year

9 Employee choice - direct contributions to Healthcare, RRSP or both - great

for people who already have spousal coverage!

9 Operates like a Health & Dental Bank Account with 24/7 online access

9 Employees can now claim expenses not normally covered!

9 Includes Esorse Hybrid Visa® Pay-Direct Health Benefits Card

9 HSA includes Excess Medical Insurance to provide additional umbrella of

critical illness protection (underwritten by the Western Life Assurance Company)

9 Everyone qualifies - no health evidence required for HSA

(employees must work at least 20 hours per week)Includes Hybrid Visa®

Pay-Direct Health Benefits Card

Works likea Health & Dental

Bank Account

enVia Benefits by Choice Flyer 101414

The enVia Benefits by Choice Program is a unique combination of a

Health Spending Account (HSA) and a Registered Retirement Savings

Program (RRSP) designed to provide employers with cost-controlled

health, dental & other benefits, and employees with much greater

flexibility in terms of what the funds can be spent on!

A better choice for both employer & employee

enVia Benefits By Choice ProgramP.O. Box 47509, 946 Lawrence Ave. East, Don Mills, ON M3C 3S7

416-453-9430 phone | 1-877-755-9670 toll-free | 416-446-7371 fax | info@envia.ca

Benefits by Choice

RRSP option provides greater flexibility:

Employees who have adequate health and dental coverage through a spousal plan, or who enjoy

good health and have few medical claims each year may choose to direct some or all of the

employer contribution to an RRSP. A variety of investment options are available to the employee,

and the amounts allocated to the RRSP vest immediately.

Scotiabank® is a Registered trademark of The Bank of Nova Scotia. * Visa Int./Lic. user The Bank of Nova Scotia.Excess Medical Insurance underwritten by the Western Life Assurance Company.

enVia

Sample claimable expenses:Acupuncture (BC only)* Occupational Therapist

Artificial Limbs Optician

Athletic Therapy* Optometrist

Attendant Care Orthodontics / Dental Braces

Birth Control Pills** Orthopedic Shoes

Breast Reduction Surgery Oxygen & Equipment

Chinese Medicine* Physiotherapist

Chiropodist Podiatrist

Chiropractor Prescription Drugs

Contact Lenses** Psychologist

Contraceptive Devices** Psychotherapy*

Crowns & Bridgework Psychiatrist

Dental Implants & Veneers Registered Masseur

Dental Treatment Skin Care (Non-Cosmetic)***

Dentures Therapy Equipment

Dermatologist Fees*** Van/Vehicle Conversions****

Fertility Treatments Vein Removal

Gastric Bypass / Stapling Viagra®, Cialis®, Levitra®

Hydrotherapy** Vitamins**

Insulin & Diabetic Supplies Wheelchairs

Laser Eye Surgery X-rays

& more****

* Must be performed by a licensed medical practitioner;** Must be prescribed by a licensed medical practitioner

and dispensed by a licensed pharmacist / medical practitioner as part of their medical services;

*** Must be medically necessary;**** As per Section 118.2 (2) of the Federal Income Tax Act and

Income Tax Folio S1-F1-C1 Medical Expense Tax Credit.

enVia Benefits By Choice ProgramP.O. Box 47509, 946 Lawrence Ave. East, Don Mills, ON M3C 3S7416-453-9430 phone | 1-877-755-9670 toll-free | 416-446-7371 faxwww.envia.ca info@envia.ca

Employer establishes Defined Contribution

Amount per Employee e.g. $1,000/year

Employee allocates to

HSA Only

Employee allocates to

HSA and RRSP

Employee allocates to

RRSP Only

3. Employee allocates the employer contribution based on their personal anticipated needs.

1. Go to the pharmacy, dentist or other healthcare provider.

2. Present your ESORSE Hybrid Pay-Direct Health Benefits Card.

3. Claim is processed.

4. Funds drawn from your Health Spending Account.

TRANSACTION

COMPLETED

The enVia HSA functions as a health &

dental “bank account” to which the employer

makes a pre-defined annual or monthly

contribution. This amount remains fixed

for as long as the employer wishes - and

is not subject to the annual inflationary

cost increases imposed by insurers under

a typical group benefits plan. This budget-

friendly “defined contribution” approach lets

the employer enjoy fixed & predictable cost

control.

enVia Benefits by Choice Flyer 101414

Benefits by Choice

Meanwhile, the employee decides how the available funds will be spent to

meet his/her personal protection needs. This can mean directing all of the funds

to a Health Spending Account or to an RRSP, or to a combination of both! Most

importantly, employees can now claim expenses not normally covered by

a traditional health & dental plan - things like Laser Eye Surgery, Orthodontia,

Dental Implants and even the therapy costs for Autistic children, for example.

How it works:1. At the policy anniversary date each year, the employer determines the amount to contribute per employee for the next year.

2. There is no requirement to increase this amount unless the employer wishes to do so. The amount can range from a minimum of $1,000 to over $50,000 per year per person.

4. “Inflationary and trend” factors imposed by insurers under traditional health and dental programs disappear! Employer gets fixed, determinable costs while employee enjoys better, more flexible coverage.

Welcome to the enVia Benefits by Choice Program!We know that filling out insurance applications can sometimes be confusing and complicated, so we’ve made every effort to simplify the process. Please use the following points to assist you in completing the necessary forms. They will help you to complete the application accurately and allow us to process your information as quickly as possible.

Which Forms do you need to complete?You need to complete:1. The attached enVia Benefits by Choice Application Form;2. The RRSP Enrolment Form only if you are allocating a portion of the employer contribution to the RRSP. Please contact Maclagan Inc. to request an

RRSP application form.3. The Chronic Conditions Reporting Form4. If you are applying for Optional Life, you must complete an Evidence of Insurability form. We will forward the form upon receipt of your

application.

About enVia “Benefits by Choice”:Under the Benefits by Choice Program your employer contributes a “defined amount” per employee to what we call the “Flexible Component”. You decide how to allocate this amount: e.g. 100% to the Health Spending Account (eHSA); or a portion to the eHSA and the balance to the RRSP; or 100% to the RRSP. Your choice is based on personal needs and whether you have health and dental coverage through a spouse’s plan. Your employer will advise you of the “defined amount” they are contributing to your account.

Your employer may also make available the option of entering into a “Compensation Adjustment Agreement” in order to make additional contributions to your eHSA. In effect, you would agree to a reduction in pre-tax pay, with the amount of the reduction being redirected to your Health Spending Account. A separate written agreement with the employer is required.

If you have allocated any funds to the RRSP, you may also elect to make additional voluntary contributions to it.

If your spouse is insured under another Health Care plan:Please provide information on your spouse’s plan. Usually it’s best to claim from the spousal plan first, and then use the Health Spending Account for expenses the spousal plan doesn’t cover, or doesn’t cover fully, i.e. co-pays or deductibles.

Declaration & Authorization:Sign and Date the Application in Section 6, and forward it to the address indicated.

Do you need any other forms?If you require the separate application for the RRSP please contact us.

Please Note:Insurance coverage under the enVia Benefits Program becomes effective on the first of the month coincident with or next following receipt of the completed application, provided that you have completed the required eligibility waiting period of employment, determined by your employer.

Booklets and pay-direct cards, if applicable, will be issued as quickly as possible. This could take a few weeks. In the meantime if you incur medical or dental expenses pay for the service, obtain a receipt and submit a paper claim for reimbursement. Claim forms will be sent with the booklet.

Application InstructionsenVia Benefits by Choice Program

Questions? Need assistance? Please contact us - we’ll be pleased to help!Telephone: (416) 453-9430 Fax: (416) 446-7371 E-mail: info@envia.ca

Please submit this Application and, if applying for Optional Life, the Personal Health Declaration. For more information or assistance in completing this application, or to request additional applications & health statements, please contact MACLAGAN INC. at 1-877-755-9670

YOUR NAME MARITAL STATUS

LAST NAME FIRST NAME INITIAL

DATE OF BIRTH (DD/MM/YYYY) SEXMALE FEMALE

MARRIED SINGLE COMMON-LAW OTHER ___________________________

LANGUAGEENGLISH FRENCH

Section 1: General Information

PRIMARY OCCUPATION

HOME ADDRESS CITY PROVINCE POSTAL CODE

HOME TELEPHONE WORKPLACE TELEPHONE FAX

EMAIL ADDRESS

MEMBER FIRM

YOUR EMPLOYMENT STATUS

BUSINESS ADDRESS CITY PROVINCE POSTAL CODE

HOURLY

enVia Benefits by Choice Program Application Form 101414

enVia Benefits by Choice Program Application Form

FULL-TIME EMPLOYEE

ANNUAL EARNINGS

Section 2: Dependent Information

Last Name First Name & Initial Sex (M/F) Birthdate (DD/MM/YYYY) Child Aged 21-25 (or 25+ if Disabled)

Spouse:

Child:

Child:

Child:

Child:

Child:

If a Child is over age 21, state if a Student or Disabled. Students only covered up to age 25 and must provide proof of attendance at school (ie. a copy of their student card).

STUDENT DISABLED

STUDENT DISABLED

STUDENT DISABLED

STUDENT DISABLED

STUDENT DISABLED

Section 3: Benefit Coverage

enVia “Benefits by Choice” Program

$ _____________ / month to eHSA

Single Plan Couple Plan Family Plan

Employee allocates funds to:

$ _____________ / month to RRSP

(Please note a separate application is required for the RRSP and contributions are considered taxable income;

you will, however, be issued an official tax receipt to claim on your personal Income Tax Return)

(If you have allocated any funds to the eHSA above, please indicate your coverage level here)

I wish to make additional voluntary contributions to the Group RRSP in the amount of $ _________________ per month.

I have entered into a “Compensation Adjustment” with my employer in order that additional contributions of $ ______________ per month will be made by my employer to my eHSA. (Separate written agreement with employer required)

OPTIONAL:

DATE OF HIRE (DD/MM/YYYY)

Employer contributes “defined amount” of $ ___________________________ per month to Program.

(please indicate how much of the monthly contribution to allocate to the eHSA, the RRSP or a portion to each)

(enVia Health Spending Account - includes $1M Excess Medical

Insurance with Deductible of $2,500)

r

r r

Section 4: Beneficiary Designation for AIG Insurance Company of Canada AD&D:

BENEFICIARY(IES) SURNAME(S), GIVEN NAME(S) & INITIAL(S)__________________________________________________________________________

RELATIONSHIP OF BENEFICIARY TO INSURED______________________________________ . If beneficiary is under age of majority, please complete

TRUSTEE section.

I, the undersigned applicant, hereby appoint the person(s) stated as my beneficiary(ies) on my current and future insurance benefits and understand

that I may, without restriction, change my beneficiary at any time in the future.

Applicant’s Signature X_________________________________________________________________________________Date________________________________

DECLARATION APPOINTING TRUSTEE (complete if beneficiary is under age of majority)

I do hereby appoint_______________________________________________as Trustee to receive any amount due to any beneficiary under the age

of majority and declare receipt of such Trustee shall be in good discharge to the insurer for the amount so paid. And I hereby authorize such Trustee,

within his/her discretion, to expend all or any portion of such amount and/or the income therefrom for the maintenance or education of such minor.

Dated at___________________________this____________________________day of________________________________________________________20_________

Applicant Signature X________________________________________________________. You must also sign the Declaration & Authorization below.

REVOCABLE IRREVOCABLE

Section 5: Declaration & Authorization

Signature of Plan Member (in full) Date (yyyy/mm/dd)

X

enVia Benefits By Choice Program P.O. Box 47509946 Lawrence Ave. EastDon Mills, ON M3C 3S7

Phone: (416) 453-9430Fax: (416) 446-7371

E-mail: info@envia.ca

Please mail this application to the address below. (To speed up the approval process, applications can be faxed or e-mailed, however the signed original must be submitted by mail within 30 days to be kept on file by the administrator.)

I acknowledge that Personal Information collected with this Application for a Health Spending Account (including Excess Medical Insurance and Accidental Death & Dismemberment Insurance) is confidential and will not be used for any purpose other than in conjunction with this request for, and subsequent administration of, the health insurance protection that is afforded to Applicants, Spouses, and Dependent Children under this plan.

I understand that this application is for a Health Spending Account established in accordance with Section 118.2 (2) of the Federal Income Tax Act and Income Tax Folio S1-F1-C1 Medical Expense Tax Credit, and includes coverage for Excess Medical Insurance and Accidental Death & Dismemberment Insurance.

It is administered by Esorse Corporation, a Pharmacy Benefits Manager and Third Party Administrator. Esorse will not be liable for any claims where the participant failed to provide complete and accurate information. I understand that claims must be submitted within 30 days of the end of a calendar year for the claims incurred in the prior year, and that unused funds carry forward for one year only and if not used then are forfeited to the contributing employer. The funds are held in a Trust Account by Esorse and no interest is credited. Unused funds cannot be returned to individual participants.

The Excess Medical Insurance is underwritten by the Western Life Assurance Company, and the Accidental Death & Dismemberment Insurance is underwritten by the AIG Insurance Company of Canada.

This program may be terminated at anytime by either party on 30 days written notice. This Application/Enrolment form together with the participant booklet constitutes the entire Agreement. No Agent, Broker or other person has authority to waived any condition of this Agreement.

Participants will be able claim up to the balance in their account at anytime and may access their account status online 24/7.

PRIVATE & CONFIDENTIALPre-Existing / Chronic Condition Reporting Form for Excess Medical Insurance

Purpose: To report confidentially any chronic or pre-exisiting conditions, treatments or medications.

Why: While participants are immediately covered for any eligible newly diagnosed conditions, treatments or medications, there is a 24 month waiting period from your effective date of coverage for any pre-existing or chronic conditions before those expenses will be covered / reimbursed under the Excess Medical Insurance Policy. THIS ONLY APPLIES TO THE EXCESS MEDICAL INSURANCE - YOUR HEALTH SPENDING ACCOUNT STILL ALLOWS YOU TO CLAIM ANY ELIGIBLE EXPENSE FROM DAY ONE.

Scope: This form should be completed both for the applicant and any eligible dependents.

Will reporting a condition have any impact whether or not I get approved? No, the plan is offered on a guaranteed issue basis. Reporting a pre-existing or chronic condition here only allows the administrator to determine the date after which your current medications / treatments will be covered / reimbursed under the Excess Medical Insurance Policy.

What will happen if I fail to report a pre-existing or chronic condition? Failure to disclose pre-existing or chronic conditions may result in the rejection of certain drug / treatment claims and / or termination of all coverage.

Will my employer be made aware of any information on this form? No, this form is strictly confidential. The information provided will be kept confidential and will not be shared with your employer or any party other than the Insurer and the Administrator, Esorse Corporation, the provider of the Pay-Direct Drug Card.

Name: ______________________________________________________ Employer: _______________________________________

Email: ______________________________________ Home Tel: ___________________ Work or Mobile Tel: ____________________

List Pre-Existing / Chronic Conditions Medications being taken Applies to (Self or Dependent’s name)

Prescribing Physician’s Name & Telephone Number

I certify the above information to be a full and complete disclosure of any and all of my or my dependent’s pre-existing or chronic conditions of which I am currently aware and treatment has been received or counselled and/or for which medication or treatment has been prescribed or recommended. I agree that the Insurer or its Service Providers may, if necessary, contact my or my dependent’s personal physician to determine the nature of a condition for which medication has been prescribed. ___________________________________________________________ _________________________(Signed) (Date)

Please retain a copy for your records and mail the completed form directly to:

PRIVATE & CONFIDENTIALenVia Benefits ProgramP.O. Box 47509946 Lawrence Ave. EastDon Mills, ON M3C 3S7

Or FAX this form to: 416-446-7371

If you have any questions or require assistance please contact:Scott Maclagan at: toll-free 1-877-755-9670 ext. 2; email: info@envia.ca